NCC242580_FRO Submitted_20240823

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
No person may initiate any land-disturbing activity on one or more acres as covered by the Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by the
Land Quality Section, N.C. Department of Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A.
1. Project Name The HUB Gas Main Extension
2. Location of land-disturbing activity: County Durham City or Township Durham
35° 53' 36.96" N 78° 52' 2.64" W
Highway/Street 3200 NC-54 HWY Latitude 35.8936° Longitude -78.8674°
3. Approximate date land-disturbing activity will commence:August 16, 2021
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Utility- Linear
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.7 acres
Express:$500
Regular:$130
6. Amount of fee enclosed: $Total:$ 630 . The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Bobby Ley, P.E. E-mail Address [e-mail]
Telephone [phone] Cell# 803-201-2539 Fax# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
See Attached Table 1
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. See Attached Page No.See Attached Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Public Service Company of North Carolina, Inc. [e-mail]
Name E-mail Address
P.O. Box 1398 800 Gaston Road, Building A
Current Mailing Address Current Street Address
Gastonia NC 28053 Gastonia NC 28056-9486
City State Zip City State Zip
Telephone [phone] Fax Number 803-217-7810

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
CT Corporation System(NCSOS ID#0519077)
Attn: Andrew Moo-,,Project ID#00b9542i [e-mail]
Name of Registered Agent E-mail Adicress
160 Mine Lake Ct Ste 200 160 Mine Lake Ct Ste 200
Current Mailing Address Current Street Address
Ralei ih NC 27615 Ralei :h NC 27615
City State Zip City State Zip
Telephone [phone] Fax Number 803-217-7810
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
S&ME, Inc. [e-mail]
Engineering Firm or other consultant E-mail Address
Matthew H.Kunkle,P.E. 704-523-4726 704-525-3953
individual contact person(type or print) Telephone Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided by me
under oath (This form must be signed by the Financially Responsible Person if an individual or his attorney-in-
fact, or if not an individual, by an officer, director, partner, or registered agent with the authority to execute
instruments for the Financially Responsible Person). I agree to provide corrected information should there be
any change in the information provided herein.
Andrew Moore Director- Engineering &Construction
Type or print name Title or Authority
11/�ek July 1, 2021
Signature Date
I, O a 4 1 t. MVUj () , a Notary Public of the County of Cnsbn
J � 1
State of North Carolina, hereby certify that reAA) 1\kO(rt appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal,this day of \ 1l- fl _ , 20
r J Y 'U
qCYNTHIA M. ALVARADO Not
s NOTARY PUBLIC Q C
Gaston Gaunty ' My commission expires 02 5
North Carolina �
my
Commission F_xpines j o�— 25